Understanding OPQRST

After my post/rant about the overuse and misuse of the DCAP BTLS TIC acronym in EMS education, I was asked the question, ” Well, are there any acronyms that you do find useful?” And the answer is an emphatic yes. Some acronyms make for useful mnemonic devices to help us recall needed information in stressful situations. Despite my strongly worded warning about the use of acronyms, I think there are several good ones that have valid clinical uses.

For sure one of the more useful acronyms I’ve learned is OPQRST. I learned it back in EMT school in 1989 and I’ve been using it ever since. I can’t imagine how many times I’ve gone through these letters in my mind while meandering through a subjective assessment with a patient.

This is an acronym that has stood the test of time, which is saying a lot in the word of emergency medicine. Considering everything that has come and gone in the last three decades of EMS evolution, the most remarkable thing we can say about OPQRST is that it has endured.

Today lets dive a little deeper into the nature of OPQRST questioning. What does OPQRST mean? When should we use it? What kinds of questions should you be asking to get the information we’re looking for and where does the OPQRST standard fall short of providing us with a complete picture of a patients pain.

Let’s start with when we should pull OPQRST out of our toolbox.

The mnemonic was created to address patients having pain of a non-specific origin. I mean to say that if you’re not sure what’s causing the pain, pull out OPQRST and give it a whirl. The patient has lower right quadrant pain? Let’s do some OPQRST. The patient has a twisted right ankle? We can keep the OPQRST questions in the bag.

There are some non-pain related complains that can be addressed with OPQRST as well. Shortness of breath fits the bill so well that the National Registry medical skill sheet uses OPQRST in the respiratory column as well as the chest pain column. Nausea and dizziness are two other complaints that we can apply to OPQRST as well. (We can probably skip the Q.)

Before we jump into what the letters mean I’d like to offer a warning about the words associated with the acronym. Like many acronyms, OPQRST has some fancy, pretty words attached to it. The words are a prompt in your head. They aren’t the best words to use when talking to your patient.

I get a bit annoyed when I hear caregivers talking to their patients about onset, radiation and provocation. For your patients sake, re-frame the words of the mnemonic into something easier to talk about. Your interaction show feel like a conversation, not a scholarly dissertation.

OK, let’s get to it:

Onset. We want to know what was happening when this all started. What was the patients physical state and what was their emotional state when this all began? Does the patient feel the pain is associated with the thing they were doing? This also gives us clues as to how long the patient was willing to endure the pain before calling. Also try to address how sudden the pain came on. Was it a rapid onset or was it gradual? This will help us wrap our brain around chronic vs acute presentations.

O – questions: “When did this all start?”, “What were you doing?”, “How were you feeling right before this started?”, “How many hours ago was that now?”, “Did it come on suddenly or gradually?”, “Do you think this pain could be related to lifting all those tires, mowing your lawn, fighting with your wife, sitting on that church pew?”

Provocation / Palliation. We want to know what makes it better or worse. What types of external factors have worked to alleviate the pain (Palliation) and what things have made it increase. This includes our palpation of the region.

P – Questions: “Has anything made it feel better since it started?”, “What makes it feel worse?”, “Does it hurt more when I push on it?”, “Does it hurt when you take a deep breath?”, “Does leaning forward like that make it feel better?”

Quality. We want to know how the pain feels. Of all the OPQRST questions, this one probably gives the patient the most trouble. Some folks just really struggle to come up with words to describe how the pain feels. This is when it becomes easy to lead the patient and we have to take care not to do that. If you give examples, try to give to opposite alternatives.

Q – questions: “What words would you use to describe this pain?”, “Can you tell me how it feels?”, “Is it more sharp or dull?”, “Would you describe it as a pressure, an ache, a stabbing pain, a burning pain, a tearing pain?”, “What would need to happen to me to make me feel that pain?”

Radiation / Region. We want to know where it is and where it goes. I tend to start this line of questioning by picking up the patients index finger and asking them to point directly to the pain. This gives a good location and also gives me some insight regarding if the pain is specific or in an area. Then I ask if it stays there or goes anywhere else.

R – questions: “if you could point with this finger, where is the pain right now?”, “Has it always been right there?”, “Where else does it go?”, “Does it move anywhere?”

Severity. We want to know how bad it is. I recommend using the 1-10 pain scale to have the patient rate their pain. It’s simple and no more or less accurate than any other pain rating scale. I described the 1-10 pain scale in some detail a few weeks back. Keep in mind that the severity scale also allows you to trend where the pain has been and recognize if your pain management strategy is working.

S – questions: “On a scale from one to ten, ten being the worst pain you have ever felt and one being a mild headache, what number would you give this pain you’re having right now?”, “What number was it when it started?”, “What number was it when it was at its worst?”

Time. When want to know when the pain started and if it has been constant, colicky or wave-like. You may have addressed the exact time the pain started in your onset questions. If your still fuzzy, nail it down here. Then try to get an idea of the pains progression. Has it been constant or irregular. If it is irregular does it come in a predictable pattern or are the waves random?

T – questions: “Do you know exactly when it started?”, “What TV show was on when this started? – Were you at the beginning or the end of American Idol?”, “Has the pain been non-stop since then or does it come and go?”

There are some additional things to keep in mind when using the OPQRST tool.

First, recognize that each letter represents a concept regarding the nature of a patient pain or symptom. Sometimes we teach OPQRST in away that makes it seem like it is a list of six questions. It’s not. It represents six ideas that you need to explore. When you start at O, don’t stop asking onset type questions until you feel like you have a firm grasp of the onset of pain event. When you get it, move on.

Second, there are two halves to every conversation. After you’ve asked the question, stop and listen to the answer. If you were talking with this person over diner and you asked a question, you wouldn’t ask it and then immediately reach for the mashed potatoes and tell your brother to turn on the UFC fight. (OK, maybe if they were really good mashers and Chuck Liddel was fighting.) But we do this to the patient all the time. Ask, listen, repeat.

Last, remember that OPQRST doesn’t always give us a complete picture of the pain. There are a few other considerations you might want to add after you’ve run out of letters. Here are a few holes you might still want to plug up after the OPQRST line.

Consider if there are any other associated symptoms related to the pain or symptom. Chest pain is one animal, chest pain with associated shortness of breath is a whole other creature. Are there other symptoms we need to consider?

A huge, very telling question that often gets left out is, “Have you ever had a pain like this before?” Your patients previous experiences with similar pains can be very helpful.

What else do you throw in with your subjective pain evaluations? This is a huge topic and I’m sure I haven’t covered it all. What other questions have you found useful?

Comments

In addition to time being “when did this start?” I also tend to think of time as “Is this the first time?” You mentioned that, but I just remember to throw it in with T. This can be pertinent history for a traumatic injury as well – have you ever hurt this ankle before?

After learning OPQRST, an acronym that I was taught was OLD CARTS (onset, location, duration, character, associated S/S, radiation, treatment/timing, severity) – it never jived with me but made me realize I should expand OPQRST into a better mnemonic (for scenario/service testing/competition where completeness counts).

If I feel I missed something, I use OLDER(T)-PQRST.
(ODLRE makes more sense, but is not a great mnemonic). I would love to hear of better ones.

Onset
Location
Duration
Event Hx (what led to this)
Reproducibility (move, palpate, breathe)
–> Timing (change/better/worse over time, has this happened before?) – this is a critical component to EACH of the above “OLDER” criteria, as well as the “PQRST”.

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[…] After that we pushed our understanding of The 1-10 Pain Scale and talked a bit about the gear we carry in What’s In Your Pockets? I asked you to make peace with the idea that much of your medicine is Simply Wrong and gave you some tips to Make Sure Your Hand-Off Report Gets Heard. For my contribution to The Handover Blog Carnival, I discussed My First Cardiac Arrest and then dove into the Use of OPQRST. […]